Comparative immunohistochemical assessment of craniopharyngioma and related lesions.

Craniopharyngiomas (CP), Rathke's cleft cysts (RCC), and sellar xanthogranulomas (XG) are closely related lesions. As expression of cytokeratins 8 (CK8) and 20 (CK20) was reported in RCC but not in CP, the present study investigates the reproducibility of immunohistochemical distinction between CP and RCC, attempting to identify the relationship of XG to these lesions. A comparative study of 55 patient specimens (25 CP, 28 RCC, and 2 XG) was analyzed for the histological features of xanthomatous changes and squamous metaplasia, and expression of CK8 and CK20. In the 25 CP cases, xanthomatous changes were seen in 5 (20%), with CK8 reactivity demonstrated in all 25 cases. A prominent xanthomatous component was identified in 13 of 28 RCC (46%), and squamous metaplasia was seen in 11 (39%), 9 of which also contained xanthomatous features. CK8 reactivity was demonstrated in all 28 RCC cases, whereas CK20 was seen only in 9 cases (32%). Of the two cases diagnosed as XG, none contained epithelium, and immunohistochemistry for cytokeratins was not observed. Overall, differential expression of cytokeratins cannot reliably distinguish CP from RCC. Furthermore, expression of CK20 in RCC is generally seen within a background of prominent squamous metaplasia and reactive xanthomatous changes.

Is routine frozen section necessary for parathyroid surgery?

OBJECTIVE: Successful parathyroidectomy requires identification and excision of 1 or more abnormal parathyroid glands. The pathologist confirms or refutes the intraoperative presence of parathyroid tissue in excised material. With the advent of radionuclide scanning and rapid parathyroid hormone assays, the role of routine frozen section (FS) has once again been called into question. Our aim was to assess the need for routine FS in tissue identification during parathyroidectomy in a series of 50 consecutive cases. METHODS: We analyzed 50 consecutive parathyroidectomies performed by a single surgeon from December 2002 to August 2003. Diagnoses on gross examination (GE) of both the surgeon and the pathologist were recorded, cytologic smears made, and FSs performed. A cost analysis was also performed. RESULTS: Of the 50 parathyroidectomies performed (35 adenoma and 15 hyperplasia), both surgeon and pathologist's opinions on GE were concordant. Incorrect gross identification occurred by both in 6% (3) of the cases. GE is a cost-effective means of identifying parathyroid tissue. CONCLUSIONS: Experienced parathyroid surgeons need not routinely request FS examination. The decision to omit intraoperative FS examination must be balanced against the potential implications of misdiagnosis and a repeat operative procedure.

Relationship of technetium Tc 99m sestamibi scans to histopathological features of hyperfunctioning parathyroid tissue.

OBJECTIVE: To investigate the histopathological features of pathologic parathyroid specimens associated with negative preoperative technetium Tc 99m sestamibi scans. DESIGN: Retrospective study. SETTING: Tertiary care center. PATIENTS: One hundred fourteen patients who underwent sestamibi scans before surgical exploration for primary hyperparathyroidism between 1996 and 2001. INTERVENTIONS: Surgical exploration and removal of parathyroid adenomas. MAIN OUTCOME MEASURES: Histopathological characteristics associated with true-positive and false-negative sestamibi scans, including parathyroid specimen weight, size, relative oxyphil and chief cell content, parathyroid hormone staining patterns, cellular architecture, and various immunohistochemical staining patterns. RESULTS: Twenty-three (24%) of 98 patients with parathyroid adenomas had negative sestamibi scan results. Among 20 age- and sex-matched patients with false-negative results vs 20 patients with true-positive results, tumor size (P = .04) and oxyphil cell content (P = .03) were found to be significantly different. CONCLUSION: Parathyroid gland size and oxyphil content are descriptive and predict differences between sestamibi properties of parathyroid adenomas but have no current therapeutic implications for parathyroid surgery.

Granular cell tumor: immunohistochemical assessment of inhibin-alpha, protein gene product 9.5, S100 protein, CD68, and Ki-67 proliferative index with clinical correlation.

CONTEXT: Granular cell tumor (GCT) is a rare tumor of nerve sheath origin with a predilection for upper aerodigestive tract, skin, and soft tissue. The neoplastic cells typically express S100 and CD68 (KP-1), the latter due to cytoplasmic lysosome content. However, the histogenesis of this tumor is unknown. Additionally, distinction between benign and malignant GCT is difficult because of histologic similarity and lack of reliable criteria that can predict clinical behavior. OBJECTIVE: To perform a comparative, side-by-side immunohistochemical assessment of the traditional immunohistochemical markers for GCTs (S100, CD68), along with the newer markers (inhibin-alpha, protein gene product 9.5) for these tumors. DESIGN: To address diagnostic and prognostic issues, we studied 30 specimens of GCT (27 primary and 3 recurrent tumors, 2 of which occurred consecutively in the same patient) for (1) nuclear pleomorphism, prominent nucleoli, necrosis, spindling, high nuclear-cytoplasmic ratio, and mitoses; (2) immunohistochemical expression of inhibin-alpha, protein gene product 9.5, S100, CD68 (KP-1), and Ki-67 using the avidin-biotin complex method on formalin-fixed, paraffin-embedded sections; and (3) correlation between tumor grade, proliferative fraction, and clinical data. RESULTS: Twenty-seven of 27 primary GCTs and 1 of 3 recurrent GCTs had typical histologic features, while the 2 consecutive recurrent GCT specimens from the same patient were atypical (moderate nuclear atypia and prominent nucleoli alone). The mean age for primary GCT was 37.3 years (range, 5-67 years), and mean size was 1.89 cm. None of the cases metastasized. All 30 specimens showed diffuse (2+ to 3+) staining for S100, CD68, and inhibin-alpha, and 3+ staining for protein gene product 9.5; pseudoepitheliomatous hyperplasia was nonreactive. The Ki-67 proliferative index was less than 1% to 20% in typical nonrecurrent cases, 1% in the typical recurrent case, and 1% and 10% in 2 sequential recurrences of the atypical case. CONCLUSION: Our study expands the immunophenotype of GCT (S100, CD68, protein gene product 9.5, and inhibin-alpha) regardless of location and supports a neural origin. Intensity of immunohistochemical staining had no prognostic significance. Although 1 of the 2 recurrent GCTs had atypical features, the Ki-67 proliferative index did not distinguish reliably between typical (nonrecurrent) and atypical or recurrent GCTs. The significance of inhibin expression with regard to cell differentiation and pathogenesis is unclear and warrants further investigation.

Sinonasal adenoid cystic carcinoma with widespread symptomatic bony metastasis.

Adenoid cystic carcinoma is a fairly uncommon salivary neoplasm of the head and neck. These lesions often progress insidiously, and they have a propensity for early perineural spread and bony invasion. Distant metastasis to the lungs is fairly common and is usually fatal. We report a rare case of adenoid cystic carcinoma in a patient who on initial evaluation had widespread bony metastasis but no pulmonary involvement.